Achilles Tendon rupture

Achilles tendon rupture is not a pleasant experience. Research suggests that the Achilles is
one of the most frequently ruptured tendons, mainly occurring in middleaged men during
sporting activities (that’s not an excuse to sit on the sofa with a brew and a chocolate biscuit).
And the incidence of ruptures is on the increase.

There are two main schools of thought when it comes to rehabilitation: surgical repair or
nonsurgical rehab. In addition, it has become common after surgery to include early
functional mobilisation, such as using an adjustable brace, and now the same approach is
being taken with promising results in non-surgical settings.

But how do we know which approach is the most effective? Patient-reported outcome scores
are an increasingly popular way to help therapists evaluate functional results and to compare
incapacity on an individual level. Several valid and reliable scores are in general use for
shoulder, knee and ankle injuries, and there are also specific scoring systems for evaluating
patients with patellar tendinosis and Achilles tendinopathy. But what if your tendon has gone
snap and you are recovering from a rupture? Researchers based in Sweden have the
solution(‘The Achilles tendon total rupture score (ATRS):development and validation’, The
American Journal of Sports Medicine2007: 35 (3) 421-426), an easily self-administered,
validated and sensitive scoring system with high reliability, which evaluates symptoms and
their effect on physical activity in patients with Achilles tendon rupture. For the first time,
clinicians have a tool that will allow them to compare and contrast different rehabilitation
modalities.

The new patient-reported outcome measure (ATRS) can be completed in a couple of minutes,
and the score from the 10 items is determined in less than a minute, providing a useful tool
for rehabilitation staff to see just how well their rehab programme is going.

Taking the strain

Tendons are specialised structures that transfer forces between muscles and bones. The
frequency, duration, and/or magnitude of tendon forces can change dramatically in response
to changes in physical activity and muscle strength, but little is known about the interactions
between muscle and tendon adaptations in living people. Researchers from California have
just completed a study to see if the Achilles tendon adapts to changes in muscle strength to
maintain strains within a preferred operating range (‘Achilles tendon adaptation during
strength training in young adults’, Medicine and Science in Sports and Exercise.

Subjects taking part in the study performed an eight-week strength-training programme (3 x

10 heel raises at 70% of maximum force) consisting of three weekly sessions separated by at
least one day of rest. They were tested before and at the end of the first, second, fourth, sixth
and eighth weeks to see if increased strength had an effect on the peak strain in the Achilles
tendon.

This is the first study to have quantified Achilles tendon strain throughout a strength training
programme; what it showed was that the Achilles seems to have a preferred strain limit that is
maintained even as muscle strength increases. The actual level of strain seems to vary greatly
between individuals.

Does eccentric loading work? It’s not just top athletes who get problems with their Achilles
tendons. A sore Achilles can also stop us mere mortals in our tracks. If you trawl through the
research you will find numerous studies expounding the virtues of different strategies for the
rehabilitation of Achilles tendinopathy, including, controversially, the use of eccentric calf
muscle training.

The use of eccentric loading to rehabilitate tendon injuries first came to light in the mid
1980s, but it wasn’t until the late 1990s that the rehab community fully embraced the
concept. While there is a lot of support for this intervention with an athletic population, there
is very little evidence to suggest that it is an effective treatment within a ‘non-athletic’
population (by which we mean you, probably most of your clients, and me!).

Researchers from Keele University School of Medicine in the UK undertook a study to fill
the knowledge gap (‘Eccentric calf muscle training in non-athletic patients with Achilles
tendinopathy’, Journal of Science and Medicine in Sport 2007: 10 52-58). To qualify as
sedentary, the patients taking part in the study had to have had a physical activity exercise
habit over a six-month period of less than three 20-min exercise sessions a week.

The patients (who all had Achilles tendinopathy) underwent a graded progressive eccentric
calf strengthening exercise programme (heel drops) for 12 weeks. They were advised to
continue the exercises through mild or moderate pain, stopping only if the pain became
unbearable.

At the start of the study the patients completed the VISA-A questionnaire – 10 questions
developed by the Victorian Institute of Sport in Australia to assess pain and activity. They
continued to complete the questionnaire at subsequent visits.

Forty-four per cent of the patients did not improve with eccentric exercise, and the
researchers concluded that, while the programme was effective in almost 60% of subjects, it
might not benefit sedentary patients to the same extent as has been reported in athletes. That
said, I’ve worked with plenty of athletes with niggly Achilles tendons, and I’ve found that
although eccentric loading worked wonders with some, it didn’t make any difference for
others…

Personally I’m not sure it has much to do with activity levels. The key is not to take a one-
size-fits-all approach. Eccentric loading is going to work for some people, and not for others.